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Commentary and Perspective   |    
Toward a New Standard in Autogenous Bone Graft?Commentary on an article by H. Claude Sagi, MD, et al.: “Qualitative and Quantitative Differences Between Bone Graft Obtained from the Medullary Canal (with a Reamer/Irrigator/Aspirator) and the Iliac Crest of the Same Patient”
S. Adam Hacking, PhD1; Mark S. Vrahas, MD1
1 Massachusetts General Hospital, Boston, Massachusetts
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None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this work are available with the online version of this article at jbjs.org.


Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 05;94(23):e180 1-2. doi: 10.2106/JBJS.L.01232
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In their study, Sagi et al. harvested autograft from the iliac crest (ICBG) and the medullary canal of the same patient for comparison by molecular techniques and histology. This is a timely study, as the use of reamed autograft tissue is gaining recognition as a source of autologous bone and cells1. This technique allows a relatively large volume of bone to be harvested during the same operative setting, and in some cases from the same limb being treated. As a result, the use of reamed autograft may reduce the number of operative sites, operative time, and potential complications. These are all compelling arguments to consider the use of reamed autograft; however, the potential impact of this technique, of this paper, and of work in this field may be far greater.
At the most basic level, bone formation is the coordinated result of osteogenic cells, growth factors, and an appropriate substrate. Growth factors are readily available and many substrates, both natural and artificial, have been approved for clinical use. The same cannot be said for osteogenic cells, and a safe and efficient cell source remains elusive. Although the reaming procedure harvests bone, the harvest of cells for delivery in the same surgical setting may be the most important application of this technique2,3. This study yielded two important findings with regard to a source of osteogenic cells. Compared with ICBG, reamed autograft samples contained more mesenchymal stem cells, and the cells in reamed autograft samples showed an overexpression of receptors for bone morphogenetic proteins (BMPs) and vascular endothelial growth factor (VEGF). Both the finding that the reamed autograft samples contained more osteoprogenitor cells and the finding that this cell population may be more amenable to stimulation by growth factors bode well for the potential for bone repair. The latter finding is of great interest since other work has shown that reamed autograft also possesses increased levels of growth factors that are commonly associated with bone repair4-6.
This discussion would not be complete without carefully considering the bone substrate obtained by each of the techniques. This is of great importance since bone formation requires a substrate and the impact of differences between the bone particulates obtained by each technique may provide important avenues for future optimization. Histologic analysis of the reamed autograft determined that the bone fragments were notably smaller and less complex than those obtained from the iliac crest. The most obvious impact of the particle size difference was on the handling characteristics of the retrieved grafts; the reamed bone was more like a fluid, whereas the bone obtained from the iliac crest was more like a solid. Fractionation of the tissue product harvested by medullary reaming would allow the cells, bone particles, and/or aspirate to be combined with other materials. For example, bone particles may be replaced, processed further, or applied to act synergistically with allograft, calcium phosphate-based materials, or porous metals7. Likewise, growth factors or other stimuli may be incorporated to enhance and guide cell differentiation8,9.
As others have clearly stated, the greatest clinical impact of reamed autograft may ultimately be its ability to provide the surgeon with an on-demand source of mesenchymal stem cells. The flexibility to choose how these cells are applied has the potential to provide new options that improve patient care in difficult cases that require extensive bone reconstruction and formation.
Cox  G;  Jones  E;  McGonagle  D;  Giannoudis  PV. Reamer-irrigator-aspirator indications and clinical results: a systematic review. Int Orthop.  2011 Jul;35(  7):951-6.  Epub 2011 Jan 18.[CrossRef]
 
Cox  G;  McGonagle  D;  Boxall  SA;  Buckley  CT;  Jones  E;  Giannoudis  PV. T The use of the reamer-irrigator-aspirator to harvest mesenchymal stem cells. J Bone Joint Surg Br.  2011 Apr;93(  4):517-24.[CrossRef]
 
Henrich  D;  Seebach  C;  Sterlepper  E;  Tauchmann  C;  Marzi  I;  Frank  J. RIA reamings and hip aspirate: a comparative evaluation of osteoprogenitor and endothelial progenitor cells. Injury.  2010 Nov;41  Suppl 2:S62-8.[CrossRef]
 
Porter  RM;  Liu  F;  Pilapil  C;  Betz  OB;  Vrahas  MS;  Harris  MB;  Evans  CH. Osteogenic potential of reamer irrigator aspirator (RIA) aspirate collected from patients undergoing hip arthroplasty. J Orthop Res.  2009 Jan;27(  1):42-9.[CrossRef]
 
Schmidmaier  G;  Herrmann  S;  Green  J;  Weber  T;  Scharfenberger  A;  Haas  NP;  Wildemann  B. Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation. Bone.  2006 Nov;39(  5):1156-63.  Epub 2006 Jul 25.[CrossRef]
 
Stannard  JP;  Sathy  AK;  Moeinpour  F;  Stewart  RL;  Volgas  DA. Quantitative analysis of growth factors from a second filter using the Reamer-Irrigator-Aspirator system: description of a novel technique. Orthop Clin North Am.  2010 Jan;41(  1):95-8;  table of contents.[CrossRef]
 
Tzioupis  C;  Panteliadis  P;  Gamie  Z;  Tsiridis  E. Revision of a nonunited subtrochanteric femoral fracture around a failed intramedullary nail with the use of RIA products, BMP-7 and hydroxyapatite: a case report. J Med Case Rep.  2011 Mar 1;5:87.[CrossRef]
 
Giannoudis  PV;  Dinopoulos  HT. Autologous bone graft: when shall we add growth factors?Orthop Clin North Am.  2010 Jan;41(  1):85-94.[CrossRef]
 
Miller  MA;  Ivkovic  A;  Porter  R;  Harris  MB;  Estok  DM  2nd;  Smith  RM;  Evans  CH;  Vrahas  MS. Autologous bone grafting on steroids: preliminary clinical results. A novel treatment for nonunions and segmental bone defects. Int Orthop.  2011 Apr;35(  4):599-605.  Epub 2010 Apr 23.[CrossRef]
 

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References

Cox  G;  Jones  E;  McGonagle  D;  Giannoudis  PV. Reamer-irrigator-aspirator indications and clinical results: a systematic review. Int Orthop.  2011 Jul;35(  7):951-6.  Epub 2011 Jan 18.[CrossRef]
 
Cox  G;  McGonagle  D;  Boxall  SA;  Buckley  CT;  Jones  E;  Giannoudis  PV. T The use of the reamer-irrigator-aspirator to harvest mesenchymal stem cells. J Bone Joint Surg Br.  2011 Apr;93(  4):517-24.[CrossRef]
 
Henrich  D;  Seebach  C;  Sterlepper  E;  Tauchmann  C;  Marzi  I;  Frank  J. RIA reamings and hip aspirate: a comparative evaluation of osteoprogenitor and endothelial progenitor cells. Injury.  2010 Nov;41  Suppl 2:S62-8.[CrossRef]
 
Porter  RM;  Liu  F;  Pilapil  C;  Betz  OB;  Vrahas  MS;  Harris  MB;  Evans  CH. Osteogenic potential of reamer irrigator aspirator (RIA) aspirate collected from patients undergoing hip arthroplasty. J Orthop Res.  2009 Jan;27(  1):42-9.[CrossRef]
 
Schmidmaier  G;  Herrmann  S;  Green  J;  Weber  T;  Scharfenberger  A;  Haas  NP;  Wildemann  B. Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation. Bone.  2006 Nov;39(  5):1156-63.  Epub 2006 Jul 25.[CrossRef]
 
Stannard  JP;  Sathy  AK;  Moeinpour  F;  Stewart  RL;  Volgas  DA. Quantitative analysis of growth factors from a second filter using the Reamer-Irrigator-Aspirator system: description of a novel technique. Orthop Clin North Am.  2010 Jan;41(  1):95-8;  table of contents.[CrossRef]
 
Tzioupis  C;  Panteliadis  P;  Gamie  Z;  Tsiridis  E. Revision of a nonunited subtrochanteric femoral fracture around a failed intramedullary nail with the use of RIA products, BMP-7 and hydroxyapatite: a case report. J Med Case Rep.  2011 Mar 1;5:87.[CrossRef]
 
Giannoudis  PV;  Dinopoulos  HT. Autologous bone graft: when shall we add growth factors?Orthop Clin North Am.  2010 Jan;41(  1):85-94.[CrossRef]
 
Miller  MA;  Ivkovic  A;  Porter  R;  Harris  MB;  Estok  DM  2nd;  Smith  RM;  Evans  CH;  Vrahas  MS. Autologous bone grafting on steroids: preliminary clinical results. A novel treatment for nonunions and segmental bone defects. Int Orthop.  2011 Apr;35(  4):599-605.  Epub 2010 Apr 23.[CrossRef]
 
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